MARBLETOWN YOUTH AND RECREATION COMMISSION
PO Box 217, Stone Ridge, NY 12484
845-687-0800 youthandrec@marbletown.net
BASKETBALL REGISTRATION FORM
Joey Wisneski
07/05/2014
CHILD’S NAME___________________________________BIRTHDATE__________
130 Vly Atwood Road
Stone Ridge, NY 12484
ADDRESS_________________________________CITY/STATE_________________
(862)205-9045
CELL PHONE_______________________
BUSINESS PHONE__________________
irena.wisneski@gmail.com
EMAIL ADDRESS_______________________________________________________
Irena Wisneski
(862)205-9045
EMERGENCY CONTACT______________________PHONE____________________
Dr. Scott Costley
(845)338-0180
PHYSICIANS NAME___________________________PHONE____________________
NYSHIP 890914960
INSURANCE INFO______________________________________________________
Pre-existing medical conditions (e.g. allergies or chronic illnesses)
NONE
I hereby give my permission for the above to participate in the program offered by the Marbletown Youth Commission. I give my
permission for a licensed physician or licensed first aid person to administer medical aid.
I understand that the Town of Marbletown is not responsible for any injury that occurs during the activities offered by the Marbletown
Youth Commission. I am responsible for my own child’s medical coverage.
I hereby certify that I understand the Town of Marbletown’s and Rosendale’s Recreation rules and policy. I also understand that I
may forfeit future admittance to programs if I do not adhere to these policies. I agree to follow all program rules and regulations. Furthermore,
I agree to indemnify and hold harmless and defend the Towns of Marbletown and Rosendale, its officers, agents, servants and employees from
any and all claims resulting from injuries, damages and losses sustained by me as a result of participation in this program and use of the
Rondout Municipal Center.
Please remember that the job of our coaches is to instruct your child in the sport that he/she is participating in. They are not meant to
be child care providers. No child (participant or sibling) should be left unattended during our programs. If you need to leave for any reason,
please appoint a friend or relative to watch your child and to take him/her home in case of an emergency. Our goal is for your child to have a
safe and happy experience.
IW
_______The
Town of Marbletown Recreation Department the right to take photographs of my child and allow them to
use such photographs of my child for any lawful purpose, including for example such purposes as publicity, illustration,
advertising and web content.
SIGNATURE OF PARENT OR LEGAL GUARDIAN___________________________
Irena Wisneski
11/06/2019
Print Name __________________________
Date________________
Boys and Girls
Grades
K – 3 _______________
GRADES 4 – 6 ___________________